ESTES guidelines: acute mesenteric ischaemia.

PURPOSE: Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria. METHODS: A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords "mesenteric ischaemia", "bowel ischaemia" and "bowel infarction". The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group. RESULTS: The resultant recommendations are presented in this paper. CONCLUSIONS: The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.

Anterior sacral meningocele in a patient with currarino syndrome as a cause of ileus.

Currarino's syndrome (CS) is characterized by a triad of a sacral bony defect, anorectal malformations and presacral mass, most commonly an anterior sacral meningocele. Since it was first described as a syndrome by Currarino et al. in 1981, approximately 300 cases have been reported in the literature. Diagnosis of CS in adulthood is rare. We present an adult patient with CS, manifesting by an acute intestinal obstruction. To our knowledge, acute intestinal obstruction in an adult as a presentation of CS has not been reported previously. Colostomy was performed first by the general surgery team to relieve intestinal obstruction caused by the giant cyst. After the final diagnosis of anterior sacral meningocele was established, a second operation was performed for the ligation of the cyst neck through a posterior approach. The size of the cyst gradually reduced over time. A staged approach and the multidisciplinary management, with the collaboration of the general surgery and neurosurgery teams, provided a satisfactory clinical outcome.

Acute pancreatitis is associated with Ser608Leu iNOS polymorphism.

Acute pancreatitis is an initially localized inflammation of the pancreatic gland. The precise mechanisms by which aetiological factors induce acute pancreatitis are not yet known, but when initiated, common inflammatory pathways seem to be involved, with cytokines being their components of major importance. The inducible nitric oxide synthase gene (iNOS) encodes an enzyme involved in the pathway of reactive oxygen species and induced in response to infection, cytokines. iNOS is capable of generating large quantities of nitric oxide produced during inflammation. The objective of this study was to investigate the association between acute pancreatitis risk and iNOS polymorphisms. The studied single-nucleotide polymorphisms (SNPs) were Ser608Leu, resulting in an amino acid substitution, and 1173C/T and 954G/C, both in the gene promoter region that is linked to increased enzyme expression, leading to higher NO production. The genotypes for the three SNPs were determined in 93 patients with acute pancreatitis and 60 controls without pancreatitis or cancer that were matched for age and gender. Data analysis was done by conditional logistic regression. It was found that the Ser608Leu polymorphism was more frequent among cases with acute pancreatitis compared to controls (OR = 2.88; 95% CI: 1.49-5.57; P = 0.002), although no individually statistically significant associations for the other SNPs studied were detected. We suggest that iNOS Ser608Leu can be used as a marker to define the risk of acute pancreatitis.

Nutritional support in patients with gastrointestinal fistula.

Gastrointestinal fistulas (GIFs) arise as a complication of the surgical treatment of a number of malignant and non-malignant diseases. Fluid loss and electrolyte and nutritional imbalance are related to increased morbidity and mortality in these patients. A multidisciplinary approach under the leadership of the surgeon is essential for successful therapy. Because complication rates are higher in malnourished patients with fistulas, enteral or total parenteral nutritional (TPN) support should be initiated after the patient has been stabilized with respect to fluid loss, acid-base, and sepsis. Pharmacotherapy with somatostatin and octreotide has been shown to reduce fistula output and shorten closure time.

Selective conservative management of penetrating hollow viscus injuries: a report of three cases.

In this manuscript, we report three cases of penetrating abdominal injury: one with pellet injury, one with pellet injury after a bomb explosion and one with gunshot injury. All three patients were successfully managed nonoperatively. A 30-year-old male was admitted to our trauma and emergency service with a pellet injury. His physical examination revealed multiple pellet injuries in the left upper abdominal quadrant, left hemithorax, left axilla, dorsal side of the abdomen, left upper extremity, and left gluteus. The second case was a 16-year-old male admitted with a shrapnel injury after a bomb explosion. His physical examination revealed multiple shrapnel injuries in the thoracal and abdominal regions, extremities and left eye. The third case was a 30-year-old male admitted with gunshot and stab wound injury. He had multiple stab wound injuries in both lower extremities and a gunshot wound in the left posterosuperior hemithorax, left upper abdomen and left dorsolumbar region. All these cases were treated non-operatively. We advocate a policy of selective conservatism based on careful initial and subsequent serial clinical examinations and imaging techniques as needed.

Percutaneous transcatheter embolization in arterial injuries of the lower limbs.

PURPOSE: To evaluate the efficacy and safety of percutaneous transcatheter arterial embolization (PTE) in lower extremity arterial injuries. MATERIAL AND METHODS: From January 2000 to June 2004, patients who presented with a penetrating trauma of the lower limbs, along with bleeding and with no sign of ischemia or hemodynamic instability, were included in the study. The injuries were embolized by coils and Gelfoam. The efficacy of PTE was defined as its ability to stop bleeding both radiographically and clinically, and its safety was determined by the complication rate. RESULTS: There were 10 embolizations, which consisted of 5 profundal femoral, 3 superior gluteal, and 2 inferior gluteal artery embolizations. PTE was effective in all patients. There were two inguinal hematomas, which did not require any intervention, and there was a temporary renal function alteration. The mean hospital stay of these patients was 2.67 +/- 0.91 days. CONCLUSION: PTE may be an effective and safe method of treatment in certain cases with lower limb arterial injuries. However, patients should be selected meticulously by both the vascular surgeon and the interventional radiologist, and PTE should be undertaken only in experienced hands.

Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds.

BACKGROUND: The modern management of penetrating abdominal trauma has decreased the incidence of unnecessary laparotomy by using selective non-operative management protocols. However, the real benefits of physical examination and different diagnostic methods are still unclear. METHODS: From January 2000 to April 2003, we prospectively collected data on 117 patients with penetrating stab wounds to the thoracoabdominal, anterior abdominal, and back regions who had non-operative management. Clinical examination was the primary tool to differentiate those patients requiring operation. Findings of physical examination, ultrasound, computed tomography, endoscopy, echocardiography, diagnostic peritoneal lavage, and diagnostic laparoscopy were reviewed. The number of therapeutic, non-therapeutic, and negative laparotomies were recorded. RESULTS: Non-operative management was successful in 79% of patients. There were 11 early (within 8 hours of admission) and 14 delayed (more than 8 hours after admission) laparotomies performed, depending on the results of various diagnostic procedures. Non-operative management failed in 21% of patients, and the rate of non-therapeutic laparotomy in early and delayed laparatomy groups was 9% and 14% respectively. There was no negative laparatomy. CONCLUSIONS: The use of physical examination alone and/or together with different diagnostic methods allows reduction of non-therapeutic laparotomies and elimination of negative laparatomies.

Trans-sternal cardiac injury caused by a hooked needle.

Cardiac injuries remain the most challenging of all injuries seen in the field of trauma surgery. Penetrating injury to the heart generally occurs less frequently than blunt injury and most commonly injures the large anterior right ventricle. We present an unusual, and to our knowledge a previously unreported, cause of cardiac penetrating trauma in a child, involving a hooked needle (a 15 cm long, metallic device usually used for crocheting or lacemaking). A ventricular septal defect was managed conservatively shortly after the primary cardiorrhaphy. Evaluation methods for this rare presentation and its possible surgical treatments are discussed.

The case of acute appendicitis and appendiceal duplication.

BACKGROUND: Appendiceal anomalies are extremely rare malformations that are usually found in the adult population as an incidental finding during laparotomy performed for other reasons. Abnormal development of the appendix usually takes the form of a double appendix. Accompanying intestinal, genito-urinary or vertebral malformations may be present when appendiceal duplications are detected in childhood. CASE REPORT: Presented herein is a case of perforated double appendix, which causes acute abdomen in a child, without any co-existing pathology. CONCLUSION: Appendiceal anomalies are of great practical importance and a surgeon must bear them in mind during an operation. If he overlooks them, the patient undergoing surgery may experience grave consequences. They also may be a forensic issue in cases when a second explorative laparotomy reveals 'previously removed' vermiform appendix.

[Esophageal injuries]. / Ozofagus yaralanmalari.

Despite progress in the management of esophageal perforations by early diagnosis, antibiotics, monitoring, and respiratory and nutritional support, it still remains as a disasterous condition. The most common cause of esophageal perforation is iatrogenic disruption. The result in the management of esophageal perforation is influenced by several factors: localization and size of the rupture, length of delay in diagnosis, age, extent of mediastinal and pleural contamination, the presence of underlying esophageal diseases, and inflammation or tumor at the perforation localization. In this study, 7 cases of esophageal perforations in the last six years have been analysed retrospectively. In study group, there were 5 males and 2 females, and the mean age was 36 (12-75). The most common cause of perforation was gunshot injury (3 cases), and stab wound (1 case), foreign body (1 case), iatrogenic distruption (2 cases). Three patients died and four patients were discharged from hospital with recovery. Esophageal perforation is a life-threatening condition. Early diagnosis and repair reduces the morbidity and mortality.

Cervical Castleman's disease: imaging findings.

Castleman's disease, a lymphoproliferative disease of unknown etiology, rarely causes a neck mass and may mimic granulomatous, inflammatory and metastatic lymph nodes, or lymphoma with its nonspecific imaging findings. Definitive diagnosis and treatment is possible with complete surgical resection. Imaging findings of a case with Castleman's disease detected during multinodular goiter surgery and later verified through excisional biopsy are presented. This report, as far as we know, is the first evaluation of the disease with sonography, Doppler sonography, CT, MR imaging, and digital subtraction angiography (DSA) findings.